Teen & Student Sleep Intake Form

Please complete this before your session. You can download a PDF of your answers and email it to info@yoursleepclinic.com.

1) Your Details

Full name

Age

Parent/guardian email (if under 18)

School / University

Year / Course

2) Sleep Concerns

What’s hardest about your sleep right now?

How long have you had sleep issues?

Do you know what started it?

Usual bedtime

How long to fall asleep (minutes)

Night‑time wake‑ups (average per night)

Wake‑up time

What time do you need to be at school/college?

Do you nap? (minutes/day)

Screen use after 9pm (hours)

Do you use your phone in bed?

How much homework/study per night (hours)

Stress about exams/grades (0–10)

Do you have a part‑time job?

Sport or extracurricular activities (type & hrs/week)

Medical conditions

Medications or supplements

Have you ever been told you have anxiety, depression or ADHD/ASD?

Energy drinks / caffeine / vaping / alcohol?

How is sleep (or lack of it) affecting your mood, focus, or social life?

What would you like to change about your sleep?

How motivated are you to work on your sleep? (0–10)

When finished, click “Download my completed form (PDF)”. Then attach it to an email to info@yoursleepclinic.com.